Financial precarity, food insecurity, and psychological distress prospectively linked with use of potentially dangerous dietary supplements during the pandemic in the US

**Background:** The COVID-19 pandemic caused widespread psychological distress and financial hardship in the US, while the dietary supplement industry saw unprecedented growth, reaching $56 billion in revenue by the end of 2020. Supplements marketed for weight loss, cleanse/detox, energy, and immunity are often ineffective and can be dangerous, linked to cardiovascular events, liver injury, and death. Deceptive marketing may exploit vulnerable consumers, but no prior studies had examined how pandemic-related financial strain and psychological distress were associated with use of these potentially dangerous supplements.

**Methods:** This study used repeated-measures data from the COVID-19 Substudy, embedded within three US national prospective cohorts (Nurses' Health Study 2, Nurses' Health Study 3, and Growing Up Today Study). A total of 54,951 participants completed surveys across five waves from April/May 2020 to April 2021. Financial strain was assessed via a single item on concern over having enough money for essentials (baseline) and a two-item measure of food insecurity (July 2020). Psychological distress was measured using the PHQ-2 (depressive symptoms), GAD-2 (anxiety symptoms), PSS-4 (perceived stress), and Daily Hassles Scale. Outcomes were self-reported current use of weight-loss, cleanse/detox, energy, and immune supplements. Modified Poisson GEE models estimated risk ratios (RRs) and 95% confidence intervals (CIs) for associations between predictors and prevalent or incident supplement use, adjusting for sociodemographics and using inverse-probability-of-censoring weights to address attrition.

**Key Results:** At baseline (April/May 2020), current use was: weight loss 2.7%; cleanse/detox 3.2%; energy 4.4%; immune 22.6%. By the end of the study, cumulative incidence of new use was: weight loss 3.5%; cleanse/detox 3.7%; energy 4.5%; immune 21.3%. In longitudinal prevalent-use analyses, financial precarity (extreme concern over essentials) was associated with up to 1.86 times the risk of energy supplement use (RR 1.86, 95% CI 1.60–2.17) and 1.84 times the risk of weight-loss supplement use (RR 1.84, 95% CI 1.48–2.29). High food insecurity was associated with 2.35 times the risk of weight-loss supplement use (RR 2.35, 95% CI 1.64–3.39) and 2.22 times the risk of energy supplement use (RR 2.22, 95% CI 1.70–2.91). Psychological distress indicators were also associated with elevated risk; for example, high daily hassles were associated with 1.37 times the risk of weight-loss supplement use (RR 1.37, 95% CI 1.19–1.58) and 1.34 times the risk of energy supplement use (RR 1.34, 95% CI 1.20–1.49). In incident-use analyses, extreme concern over essentials was associated with 2.11 times the risk of initiating energy supplement use (RR 2.11, 95% CI 1.63–2.73) and 1.74 times the risk of initiating weight-loss supplement use (RR 1.74, 95% CI 1.26–2.41). High food insecurity was associated with 1.77 times the risk of initiating weight-loss supplement use (RR 1.77, 95% CI 1.03–3.06) but not with other supplement types. Depressive symptoms were associated with 1.46 times the risk of initiating energy supplement use (RR 1.46, 95% CI 1.29–1.64) and 1.31 times the risk of initiating weight-loss supplement use (RR 1.31, 95% CI 1.14–1.50).

**Clinical Implications:** These findings highlight that individuals experiencing financial strain and psychological distress during the pandemic were at substantially increased risk of using potentially dangerous dietary supplements. Clinicians should routinely ask patients about use of these supplements and counsel them on the risks, especially those facing financial hardship or mental health challenges. Public health nutrition professionals working with food-insecure households should be aware that these clients may still purchase expensive, ineffective supplements due to deceptive marketing. The results underscore the need for stronger FDA and FTC enforcement against deceptive advertising and for public health surveillance to monitor supplement use. The study's limitations include a predominantly white, female, nursing professional sample, which limits generalizability, and reliance on self-reported supplement use. Nonetheless, the consistent associations across multiple measures of adversity and supplement types provide compelling evidence that the supplement industry profited from vulnerable populations during the pandemic.